Patient Informed Consent EndoVenous Laser Treatment (EVLT) Procedure

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1 Patient Informed Consent EndoVenous Laser Treatment (EVLT) Procedure I (Patient or Guardian) authorize Dr. his associates and assistants, to perform Endovenous Laser Treatment of my right/left great/small saphenous vein and accessories, applying foam sclerotherapy where necessary. I understand that this means that the physician, using ultrasound guidance will direct a catheter from below to the upper end of the diseased vein, position the laser fibre, and after injecting anesthetic around the vein and in the groin close the vein with heat energy from the laser. At the same sitting, prominent surface veins, not amenable to specific laser treatment may be removed, or treated with a sclerosant, 1% Tromboject (STD) foamed with air to increase its efficacy I understand that this procedure is to correct the reverse (downward) flow in the diseased vein in my leg(s) that produces congestion and/or bulging veins. I understand that there are alternatives to this procedure such as open surgical stripping, ablation by radiofrequency rather than laser heat energy, and repeated ultrasound guided sclerotherapy, but I consent to EVLT understanding that there are risks to any invasive procedure. These risks have been explained to me. I expect that there be some bruising, swelling, tightening in the thigh, and that there may be lumps at the sites of thrombosed surface veins, that may be tender and may need needle drainage later to avoid discoloration of the skin by the blood pigment. I also understand that nerve bruising below the knee causing numbness or tingling, injury and thrombosis (clotting) of the deep (main ) vein DVT, and skin burns have been reported, but are unlikely to occur in most patients I also understand that despite the high clinical efficacy of this procedure,(over 90% success at 4 years) my physician cannot absolutely guarantee cure of my venous disorder These issues have been discussed and reviewed with me to my satisfaction, and I have read and understand this consent form. I therefore consent to the procedure above. PRINT Patient or Guardian Name Patient or Guardian Signature Witness Date

2 Endovenous Laser Treatment (EVLT) - Patient Information The Day of the Procedure Before Treatment: You may eat and drink normally before the procedure however please avoid alcohol and reduce caffeine-containing products. If you have obtained them, please bring your support stockings with you to the clinic. Please bring comfortable, loose fitting clothes that can be worn over the stockings and/or bandages. We recommend you arrange for transportation home following the procedure. Patients who have not taken sedation can drive their car (preferably short distances only). The Treatment: EVLT typically takes a total of one hour per limb to perform. We schedule your appointment for 2 hours. Please arrive minutes before the scheduled time. On arrival you will be asked to change; if your undergarments are high-cut these may be left on. The vein to be treated will be mapped out by ultrasound. A pre-treatment photograph will usually be taken. You will then lie on the treatment table and a cleaning solution used on the leg. Please remind us if you are allergic to Iodine. Sterile drapes will be placed around the treatment leg. (All materials used are sterile and are disposed after single use). Local anaesthetic ( freezing ) is placed at the entry site. A needle is placed through the skin into the center of the vein to be treated. (Rarely a small incision is made). 1

3 A guidewire is placed through this needle into the vein. You may feel this wire but it will not be painful. A sheath (tube) will be placed over the guidewire and the correct position in the vein found using ultrasound. The laser fiber will be placed into this sheath replacing the guidewire More freezing will be placed along the vein to be treated. The laser then is turned on and pulled back along the vein using heat energy to close the vein channel. This should NOT be painful. Let us know if you have pain. Sclerosant solution foamed with air may be injected via the sheath to destroy accessory veins. Occasionally, long straight accessory veins may be removed through a small incision After the laser is removed a small bandage is placed on the skin. Please remind us if you are allergic to adhesive tape. Immediately After Treatment If there are many bulging accessory veins a compression bandage may be applied over these. Your support stockings will then be placed around the leg to apply pressure to the treatment area. We encourage you to get up off the treatment table and walk for about 5 minutes to ensure the bandages are comfortable and to promote circulation. 2

4 Following EVLT Treatment The first 48 hours The stockings and or bandage must be left on continuously. You are encouraged to walk and resume normal daily activities but avoid strenuous activity. Please avoid prolonged periods of standing in place or sitting with your legs down. When sitting, please elevate you legs on a stool or chair. You may apply ice packs (on top of the bandages) over the treated areas we recommend 15 minutes every one to two hours. Take Ibuprofen (Advil or Motrin) 400mg every 4 to 6 hours to prevent or limit inflammation along the vein. You may also take Tylenol plain if you have any discomfort that is not controlled by ibuprofen. Drink plenty of non-alcoholic beverages to avoid dehydration. 48 hours to one week After 48 hours you may remove the stocking and or bandages and shower we recommend showers over warm or hot baths. Thereafter, wear your stockings from morning to night (off at bedtime) for one week Bruising along the treatment site is normal and can be reduced by applying ice as advised above. The bruising usually clears within two weeks. The varicose veins should be significantly smaller. Do not be discouraged by persisting veins, as these will continue to shrink over the next 8 weeks. Some tightness over the vein is normal and may feel like a pulled muscle we encourage you to continue walking to reduce this tightness. If you note redness or significant discomfort over the vein continue taking ibuprofen as some individuals will have a prolonged inflammatory reaction to the laser. At one week you will see the doctor and can expect to be able to return to all activities including vigorous exercise. If trapped blood is noted in surface veins it may be released. One to Eight weeks 3

5 Return to full activities. Wear your stockings all day until bedtime for at least 3 weeksthe more bulging veins you had, the longer. The vein branches will continue to shrink or disappear. Stiffness, minor swelling or discolouration over the treated area can occur and will progressively improve. At eight weeks your doctor will reassess your veins and decide if any additional (minor) treatment is necessary. 4

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